CLARK COUNTY LOBBYIST REGISTRATION STATEMENT Badge # ____________ Return Date _________ Renewal Date _______ This form should be completed for each communication with a member of the Board of County Commissioners and may be submitted to the front desk at the County Commissioner's Office or the Clerk's Office, Commission Division to obtain a "Lobbyist" badge that must be returned. Lobbyists who are registered annually need to complete Section 2 only once. Completed forms may also be submitted by fax to the County Clerk, Commission Division at 455-4626. This form can be accessed on the County's website at www.co.clark.nv.us/clerk/forms.htm SECTION 1 LOBBYIST NAME: ______________________________________________________________ APPLICATION DATE: ____________________ COMMUNICATION DATE: _________________ COMMUNICATION ITEMS: _______________________________________________________ COMMISSIONER(S) CONTACTED: ________________________________________________ SECTION 2 PERMANENT ADDRESS: ________________________________________________________ BUSINESS NAME: _____________________________________________________________ BUSINESS ADDRESS: __________________________________________________________ SECTION 3 PROVIDE THE BUSINESS NAME, FULL NAME, AND COMPLETE ADDRESS OF EACH PERSON OR ENTITY BY WHOM YOU ARE RETAINED, EMPLOYED, OR ON WHOSE BEHALF YOU ARE APPEARING TODAY: NAME/BUSINESS NAME ADDRESS PHONE _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________ SIGNATURE OF LOBBYIST _________________________ DATE *An amendment to the registration must be filed with the County Clerk, Commission Division, if there is a substantial change or addition with respect to the information contained in the original registration statement. American LegalNet, Inc. www.FormsWorkflow.com